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Care coordination

Take charge of your health and get the best care possible.

Care Coordination Services, part of Great Plains Health Innovation Network, offers care and disease management programs that can help in many ways:

• Promote a good relationship with your medical team
• Develop a sound plan of care using evidence-based guidelines
• Overcome barriers to obtaining care
• Improve your overall health
• Prevent or reduce your risk for developing chronic conditions (“chronic” means long lasting or occurring often)
• Stop a chronic disease you may have from getting worse
• Learn more about conditions you may have
• Understand the healthcare system better
• Connect you with community resources

Care Management Program

What is care management?

Care Management helps you take charge of your health. The goal is to make sure you get the right care at the right time in the right place. As a result, you could see improved health at a lower cost.

What is the care manager’s role?

A care manager is a nurse or social worker who coordinates your care. That person helps you do the following:
• Gain a better grasp of the healthcare system
• Find the resources you need
• Get the best care by serving as a link with your providers

How does this program work?

A care manager will contact you to discuss your health needs and goals. That person then develops a care plan to share with you and your provider. Once this plan is in place, the care manager will follow up with you regularly. That person may be at your provider visits or call to see how you are doing.

Disease Management Program

What is Disease Management?
Disease Management is for people who already have chronic conditions. Here are examples of chronic diseases:

• Diabetes
• Heart failure
• COPD (chronic obstructive pulmonary disease)
• Asthma
• High blood pressure
• High cholesterol
• Other mental health/substance abuse

The goal is to empower you to manage your risks and follow a healthy lifestyle.

Zone Tools

Click below to view the zone tool for each specific diagnosis:

• Diabetes
• Heart disease
• Heart failure
• Infection Prevention
• Pain
• Pneumonia
• Sepsis
• Stroke

What is the health coach’s role?

A health coach helps you create an action plan. That person also helps you understand and manage your condition. Your health coach updates your providers on your action plan, goals and progress.

How does this program work?

As part of the program, you receive educational materials, phone calls and/or in-person meetings with a health coach.

For printable brochure, click here.

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